A Little Bit Can Hurt (15 page)

POSSIBLE NEXT STEPS:

1. If you have suffered an allergic reaction after eating a specific food, have you been formally diagnosed by a qualified medical professional such as an allergist? To determine the extent of your food allergy, this diagnostic process may involve a detailed conversation regarding your eating history, skin and blood testing and even food challenges.
   
2. Have you experienced facial swelling and/or flushing or had repetitive sneezing after eating a particular food? If so, seek medical attention for an allergic reaction.
   
3. Although most food-allergic reactions occur within thirty minutes of eating the offending food, have you considered the possibility that your delayed symptoms may be the result of a food-allergic reaction?
   
4. Have you identified and trained individuals in your Food Allergy Circle, including work colleagues, to administer your epinephrine in the event you lose consciousness during an allergic reaction?
   
5. Do you wear MedicAlert
   ^®
   identification in case you're unable to communicate your medical needs and history to the EMTs?
   

Section 6

MEDICAL PROFESSIONALS

M
edical professionals such as allergists and dieticians daily encounter an increasing number of patients and their families living with varying degrees of allergic disease including food allergy, hay fever, asthma and eczema. Their professional expertise and care can make the difference between food-allergic individuals suffering the health risks associated with food allergy versus enjoying the significant benefits derived from an accurate diagnosis, educational support, treatment plan and long-term management. Working with general practitioners, allergists and dieticians aim to improve the patient's overall health by focusing on the specific allergic and nutritional challenges presented by food allergy.

Section Six lays out informative interviews with Dr. Robert Wood and registered dietician Ann Caldwell who explain:

• Food allergies and what causes them;
  
• Food allergy versus food intolerance;
  
• The rising incidence of food allergies;
  
• Types of testing for food allergies;
  
• The latest food allergy research;
  
• The role of the dietician in assisting food-allergic families;
  
• The specific concern of nutritional deficiency and associated health problems in food-allergic children;
  
• Recommended resources including how to find a reputable dietician; and
  
• Encouragement for families contending with food allergies.
  

17

ROBERT WOOD, MD

T
i
tle: D
ir
ecto
r
of Ped
i
at
ri
c Alle
r
g
y
and Immunolog
y,
Johns Hopkins Children's Center

Author of
Food Allergies for Dummies
and over 200 articles and book chapters

Website:
http://www.hopkinschildrens.org/allergy/

Question: What is a food allergy and how is it different from an intolerance such as lactose or gluten intolerance?

Answer:
The thing that most differentiates a food allergy is that it is an immune system response to a food protein. If someone has an intolerance to a food, it is usually because their digestive system can't handle that food. They may have trouble breaking it down, so it might give you symptoms of upset stomach or diarrhea, and while those symptoms can occur with a food allergy, food allergy usually has other symptoms involving the skin or breathing. Food allergy always involves the immune system whereas food intolerance never involves the immune system. Food allergy relates to the protein component of food whereas most food intolerances are related to the sugar or carbohydrate component of the food.

Q: What are the signs and symptoms of a food-allergic reaction and when should a food allergy be suspected?

A:
They range from a minor rash to severe, life-threatening anaphylaxis. We think of four systems in the body that are most often involved in food reactions: the skin, which can show hives, eczema or swelling; the GI system which could involve vomiting, abdominal pain or diarrhea; the respiratory system which could be congestion in the nose or lower respiratory reactions with difficulty breathing, cough, wheezing or swelling in the throat; and then cardiovascular reactions which can affect the heart and blood pressure. An anaphylactic reaction refers to a reaction that involves several of these systems simultaneously, which can range from something that is fairly mild and goes away or something that is life threatening or even fatal.

Q: Briefly describe the allergic march and in what ways the allergic march has changed in the past decade.

A:
The allergic march refers to a pattern where it's most common to develop food allergy and/or eczema as the first signs of allergic disease. Most of those have their onset in the first year of life, and then those children who have had food allergy and/or eczema early in childhood will usually go on to develop other allergic diseases, particularly allergic rhinitis and asthma. The allergic march has not changed at all over the last hundred years. It was described a hundred years ago. Now it may be that the prevalence of allergy may be higher, but the march itself is no different than it was a hundred years ago.

Q: Is the prevalence of allergic disease such as food allergy, hay fever and asthma increasing, and if so, why?

A:
All allergic diseases have increased over the last thirty years. It appears that the increase in asthma and allergic rhinitis actually began earlier than the increase in food allergy. Asthma and allergic rhinitis appear to be very stable over the last ten years. Food allergy, on the other hand, appears to still be rising, and the rise in food allergy from the data we have probably began after the rise in asthma, more in the range of fifteen or twenty years ago. We won't know until we look back ten years from now, but our impression would be that the prevalence of food allergy is still rising. And the reasons why are really very much unknown. There are a
dozen or so theories that are popular and have some data to support them, but none of them are even close to the full explanation.

We can talk about the three or four most popular theories. The hygiene theory is the most popular. It says we live in too clean an environment and if your immune system is not occupied by dealing with germs and bacteria early in life, it may pay more attention to allergy. There are some nutritional theories. One of them is that we don't get enough vitamin D and that deficiency in vitamin D may make you more prone to get allergy. Another is that we get too much folate and that too much folate may make you more prone to get allergy. There are theories that revolve around how food is processed, and there certainly is a very big difference in the type of foods being eaten today compared to thirty years ago. But we're not sure how that might specifically tie in to developing food allergy.

Q: We hear so much about peanut allergies now. Is peanut allergy new? What is remarkable or different about peanut allergy in this generation of children?

A:
It is certainly not new. What is different is that it is more common than it was twenty years ago, at least twice as common now as it was fifteen or twenty years ago. But the disease itself in terms of severity or risk or anything else is no different than it was fifty or a hundred or two hundred years ago.

Q: What is involved in testing for food allergy?

A:
There are four or five things. The first is a history of what the patient suspects may be causing their problems. The second is doing skin testing or blood testing that can help identify which foods may be a problem. The problem is that both the history of possible food allergy and skin and blood testing are extremely inaccurate. They are mostly inaccurate because they have a lot of false positive results where someone believes they are allergic but truly are not, or where someone tests positive with a skin test or blood test but is not truly allergic. The fourth step is doing a food challenge which is more accurate but something that should only be undertaken with good reason because it can also be very risky. The last part of diagnosis is elimination diets where you may take a food away and see if something gets better and then reintroduce a food and see if symptoms return.

Q: Please explain peanut allergy component testing and its value?

A:
Component testing is a means of looking not just for entire ground-up peanut, but looking at specific molecules within the peanut that may be more likely to be associated with a true allergic reaction. There is lots of component testing under study right now, but for foods the only one that is currently licensed is for peanut. This may be particularly useful in patients who do not have a clear history of reaction to peanut, one of these people who only have a positive test but no clear history of having a significant reaction. For people who have had a significant reaction and test strongly positive with a normal skin test or blood test, component testing does not really add anything at all. There is a belief out there that it will predict the severity of your reaction, which is not the case at all. It helps more to predict whether you're going to react or not, rather than how severe the reaction might be.

Q: Can you explain Oral Allergy Syndrome?

A:
Yes, Oral Allergy Syndrome is a condition that occurs in older children, typically adolescents and adults. It occurs because you've initially become allergic to certain pollens, and there are certain pollens that are associated with certain foods. There are some groupings, the most common being that people who have tree pollen allergy may get a reaction to fruits like apples, peaches, cherries or vegetables like carrots. It's called Oral Allergy Syndrome because the reaction is typically confined in and around the mouth. They may get an itchy mouth, an itchy throat, a little bit of swelling of their lips or a little rash around the mouth. It is for most people more of a nuisance than a dangerous allergy, so most people will decide if they enjoy an apple enough to put up with an itchy mouth or don't like the itchy mouth and will avoid the apple. And we don't think they are taking unnecessary risk by doing that.

Q: If a patient is determined to have a food allergy and is prescribed an epinephrine auto-injector for treatment, how seriously should he or she take it? And if a patient has a food allergy that does not require an epinephrine auto-injector, is this diagnosis cause for real concern?

A:
The prescribing practices for epinephrine vary a lot, so there are certainly patients who get epinephrine auto-injector prescriptions who don't really need them and there are some people who really need one and don't get one. But in
general, if your doctor has prescribed an epinephrine auto-injector for you, he or she must have felt that you are at risk of having a severe reaction, in which case you should certainly make every effort to avoid that food and have the epinephrine with you one hundred percent of the time.

Q: Can someone have a food allergy and not necessarily need an epinephrine auto-injector, just Benadryl
^®
?

A:
Oral Allergy Syndrome does not need an epinephrine auto-injector. It's usually going to go away just with waiting a few minutes or taking a drink of water. In cases that are more complicated our general approach is that unless we are really, really confident someone will not have a severe reaction, we do want to be prepared for the worst case scenario. Examples there would be if someone only got hives on his face with his first peanut reaction or first egg reaction or milk reaction. Unless I am really certain that it could not be any more severe in the future, we are going to want to protect him with an epinephrine auto-injector because he can easily go from a reaction that just has localized hives to a reaction that's very dangerous with future exposures. Back to testing, we don't have any tests that are at all useful in predicting how your next reaction is going to be.

Q: From your perspective, what is the patient's responsibility in understanding and managing his or her food allergy?